Friday, June 2, 2023
This activity is intended for urologists, medical oncologists, radiation oncologists, and other healthcare professionals who treat patients with prostate cancer.
The goal of this activity is to educate physicians regarding the latest research in the diagnosis, treatment, and prevention of prostate cancer.
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The clinical stage of a tumor and its histopathologic grade are established factors used to assess patient risk and prognosis and guide treatment decisions. Although tumor stage and grade have been used alone to predict final pathologic stage and prognosis, when combined with other independent variables in mathematical models, they more accurately predict clinical outcomes.
Anatomic-based classification of prostate cancer is described by clinical staging systems, which, together with histopathologic grading, help guide the selection of therapy and assess the risk for disease progression. The two most commonly used staging systems are the tissue, node, and metastasis (TNM) system of the American Joint Committee on Cancer (AJCC) and the Jewett system.
The TNM system classifies tumors according to features of the primary tumor, and assigns tumors to one of four main stages (T1-T4) and several substages (eg, T1c, T2c). This system also assesses the extent of tumor metastasis to regional lymph nodes (N stage) or to metastases beyond (M stage). Like the TNM system, the Jewett staging system assigns tumors into one of four major categories (stages A-D), each of which is associated with substages. According to both of these systems, stages A, B, T1, and T2 refer to clinically localized prostate cancer; stages C, T3, and T4M0 to tumors that have extended beyond the capsule; and stages D and T4M1 to metastatic disease.[8]
Cancerous tissue from prostate biopsy and prostatectomy specimens is graded histologically, based on the architecture of the glandular tissue, glandular differentiation, and cellular and nuclear appearance; this provides a relative measure of the aggressiveness of the cancer cells.[64,80,81] The most commonly used histopathologic grading system is the Gleason system, which uses a numeric scale to represent the observed histologic patterns. The primary and secondary patterns are each assigned a grade from 1 to 5, which, when added together, yields the Gleason score. This score describes the histologic differentiation of the cancer, and corresponds to broad categories of disease grade: 2-4, well differentiated (very rarely seen on needle biopsy); 5-6, well to moderately differentiated; 7, moderately differentiated; 8-10, poorly differentiated.[8]
Of note, the primary and secondary grades can also contribute prognostic information. For example, patients with 3+4 Gleason score often fare better than patients with 4+3 Gleason score.[8] In one series, patients with Gleason score 4+3 tumors had a significantly greater increased risk of developing metastatic disease compared with patients with Gleason 3+4 tumors, regardless of surgical margins and extent of extraprostatic extension.[82]
Although preoperative Gleason scores in the 2-4 or 8-10 range closely correlate with the final pathologic stage of disease on prostatectomy, there is substantial disparity in Gleason score and final pathologic stage for the 5-7 range -- the range at which most men present clinically.[83] In part, this relates to the sampling problem of prostate needle biopsies mentioned above. While the Gleason score is useful in staging prostate cancer, additional prognostic value may be obtained from the order of the assigned grades (ie, primary and secondary). Therefore, more accurate prediction of the final pathologic stage of a tumor can be made when the Gleason score is combined with information from clinical staging and PSA.[83]
